The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Prescription for ceftriaxone PO every 12 hours.

A 26-year-old client.

Blood pressure is 80/48 mm Hg.

Admitted after a motor vehicle collision.

Answer and Explanation

The Correct Answer is C

A. Prescription for ceftriaxone PO every 12 hours is not relevant in the initial "Situation" section of SBAR. This would fit better under the "Recommendation" or "Background" sections.

B. A 26-year-old client is part of the background information but does not immediately address the critical issue requiring attention.

C. Blood pressure is 80/48 mm Hg is the most urgent information and provides a clear reason for contacting the healthcare provider.

D. Admitted after a motor vehicle collision is part of the background and would follow the situation statement.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. The client will adhere to the medication regimen after discharge is an appropriate outcome statement because it is specific to the client's need to manage hyperglycemia with insulin therapy postoperatively. This outcome addresses the necessity of learning self-injection techniques and adhering to the prescribed regimen.

B. The client attempts to self-administer insulin but is unable to perform injection is not an appropriate outcome statement because it does not reflect a desired or achievable goal. It implies failure rather than a measurable improvement.

C. The client will demonstrate ability to change the ostomy bag in two days is relevant to the colostomy care but does not address the immediate need for managing hyperglycemia with insulin therapy.

D. The client's breath sounds will be auscultated by the nurse every 4 hours is a task-oriented intervention rather than a client-centered outcome statement.

A. Advise the UAP to hold the thermometer securely in place for a full three minutes. B. Use positive reinforcement to affirm that the procedure is being performed correctly. C. Demonstrate the correct technique for pulling the client's auricle down and back. D. Remind the UAP to lubricate the thermometer before gently inserting in the ear.

Correct Answer is B

Explanation

A. Advise the UAP to hold the thermometer securely in place for a full three minutes is incorrect because tympanic thermometers provide quick readings, typically within a few seconds, and do not require prolonged placement.

B. Use positive reinforcement to affirm that the procedure is being performed correctly is the correct action. For adult clients, the auricle should be pulled up and back to straighten the ear canal for accurate tympanic temperature measurement. Positive reinforcement supports the UAP's learning and confidence.

C. Demonstrate the correct technique for pulling the client's auricle down and back is incorrect for adult clients. Pulling the auricle down and back is appropriate for children under 3 years old, not adults.

D. Remind the UAP to lubricate the thermometer before gently inserting in the ear is not appropriate. Tympanic thermometers do not require lubrication, as they are designed for non-invasive and quick use.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

Correct Answer is B

Explanation

A client is being discharged postsurgery. Which information provided by the client requires additional instruction by the nurse?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls," in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Two clients ring their call lights simultaneously requesting pain medication. Which action should the nurse implement first?

While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow-up action should the nurse take first?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA) laboratory result, which action is the most important for the nurse to take?